need a html page created similar to image

I need a simple html page created , based on this image

1 - It MUST be AMP verified
2- It must NOT use too many scripts 1-2 like jquery/bootstrap is fine.
3- CSS must be inline

its going to be a landing page, so i hope you understand how important it is to have speed etc.
i have email sending code ready, just modify it according to requirements. ( will provide sample of working form)

it should not take more than 30 minutes for an experienced guy

Will pay 700 INR for it ( about 10$)
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need a html page created similar to image

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